Cost-Effectiveness of Rheumatic Heart Disease Echocardiographic Screening in Brazil: Data from the PROVAR+ Study: Cost-effectiveness of RHD screening in Brazil

Abstract

Introduction: In recent years, new technologies-noticeably ultra-portable echocardiographic machines-have emerged, allowing for Rheumatic Heart Disease (RHD) early diagnosis. We aimed to perform a cost-utility analysis to assess the cost-effectiveness of RHD screening with handheld devices in the Brazilian context. Methods: A Markov model was created to assess the cost-effectiveness of one-time screening for RHD in a hypothetical cohort of 11-year-old socioeconomically disadvantaged children, comparing the intervention to standard care using a public perspective and a 30-year time horizon. The model consisted of 13 states: No RHD, Undiagnosed Asymptomatic Borderline RHD, Diagnosed Asymptomatic Borderline RHD, Untreated Asymptomatic Definite RHD, Treated Asymptomatic Definite RHD, Untreated Mild Clinical RHD, Treated Mild Clinical RHD, Untreated Severe Clinical RHD, Treated Severe Clinical RHD, Surgery, Post-Surgery and Death. The initial distribution of the population over the different states was derived from primary echo screening data. Costs of the different states were derived from the Brazilian public health system database. Transition probabilities and utilities were derived from published studies. A discount rate of 3%/year was used. A cost-effectiveness threshold of $25,949.85 per Disability Adjusted Life Year (DALY) averted is used in concordance with the 3x GDP per capita threshold in 2015. Results: RHD echo screening is cost-effective with an Incremental Cost-Effectiveness Ratio of $10,148.38 per DALY averted. Probabilistic modelling shows that the intervention could be considered cost-effective in 70% of the iterations. Conclusion: Screening for RHD with hand held echocardiographic machines in 11-year-old children in the target population is cost-effective in the Brazilian context. Highlights: • A cost-effectiveness analysis showed that Rheumatic Heart Disease (RHD) echocardiographic screening utilizing handheld devices, performed by non-physicians with remote interpretation by telemedicine is cost-effective in a 30-year time horizon in Brazil. • The model included primary data from the first large-scale RHD screening program in Brazilian underserved populations and costs from the Unified Health System (SUS), and suggests that the Incremental Cost-Effectiveness Ratio of the intervention is considerably below the acceptable threshold for Brazil, even after a detailed sensitivity analysis. Ubels et al: Cost-Effectiveness of Rheumatic Heart Disease Echocardiographic Screening in Brazil Art. 18, page 2 of 11 • Considering the high prevalence of subclinical RHD in Brazil, and the significant economic burden posed by advanced disease, these data are important for the formulation of public policies and surveillance approaches. • Cost-saving strategies first implemented in Brazil by the PROVAR study, such as taskshifting to non-physicians, computer-based training, routine use of affordable devices and telemedicine for remote diagnosis may help planning RHD control programs in endemic areas worldwide.

Estatística Cardiovascular – Brasil 2021

“…Uma estratégia baseada em divisão de tarefas, com aquisição de imagem por não médicos, utilizando dispositivos portáteis, e telemedicina para interpretação remota por especialistas, resultou em uma razão de custo-efetividade incremental de $10.148,38 por DALY evitado, abaixo do limiar estimado de 3 vezes o produto interno bruto per capita, sugerido pela Organização Mundial da Saúde. 212 …”

Saving time saves lives! A time focused evaluation of a single-view echocardiographic screening protocol for subclinical rheumatic heart disease

“…Nevertheless, we have demonstrated that a rapid single-view screening protocol can be performed in just over one-minute with a high degree of accuracy. School-based screening programs appear to be cost effective and reduce the risk of RHD overtime [5,18,19]. As new evidence emerges and technology improves, increased funding for RHD is needed to meaningfully reduce the global burden of disease [20].…”

Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum

“…The investments required for local surgery capacity were high with limited impact (ICER of USD 23,827 per DALY averted for building a local center) [209]. Several other publications have separately explored optimum cost-effective strategies for primary prevention [210], secondary prevention [211][212][213][214], and a combination of both [214][215][216]. A most recent modeling study for the prevention and management of RHD in the African Union concluded that, "In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier [217]".…”

“…A most recent modeling study for the prevention and management of RHD in the African Union concluded that, "In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier [217]". Most analyses make use of Markov models, and similar challenges relating to lack of precise transition probabilities on which to base the calculations have been reported [209,212,215].…”